5 ACKNOWLEDGMENT This monograph is based on papers presented at a technical review conducted by Plog Research, Inc., Reseda, California, under NIDA Contract No The conference took place on September 14 and 15, 1978, in Reston, Virginia. The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this material is prohibited without specific permission of the copyright holders. 411 other material, except short quoted passages from copyrighted sources, is in the public domain and may be used and reprinted without permission. Citation as to source is appreciated. The U.S. Government does not endorse or favor any specific commercial product or commodity. Trade or proprietary names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. Library of Congress catalog card number DHEW publication number (AIM) Printed 1979 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of Biosciences Information Service, Chemical Abstracts, Psychological Abstracts, and Psychopharmacology Abstracts. iv

6 Foreword Substance abuse, including tobacco use and overeating as well as more traditional drug and alcohol abuse, is a concept increasingly central to the concerns of the National Institute on Drug Abuse. The addictive disorders which often result from such abuse are accountable for an enormous share of this nation s burden of illness and premature death. Cigarette smoking takes by far the largest toll, with excessive use of, alcohol ranking second; a smaller number of deaths is related to use of other psychoactive drugs and to overeating. Over a quarter of last year s total of 1.9 million deaths in this country are conservatively attributable to these disorders. Evidence increasingly suggests that the substance abuse concept is a useful one, that the behavioral patterns involved are basically and not just superficially related. Most individuals involved in any of these behaviors are aware of the negative consequences, frequently would like to alter their behavior, and are unable to do so. These disorders are notoriously difficult to treat, with high attrition during treatment, and high rates of relapse to use, remarkably consistent from substance to substance. Behavioral treatment programs have proliferated in recent years, more rapidly in some areas, such as obesity and smoking, than in others, such as treatment of heroin addiction; already, prematurely, they tend to fall into fairly standard patterns. Results have been mixed. Often the programs appear to show considerable success, especially in the short run. Yet effective and replicable treatments remain elusive, and little is known of the processes involved in the therapies themselves or in the behaviors they are intended to modify. This monograph is one product of NIDA s recognition of the importance of the substance abuse concept. It presents a variety of views on both methods of behavioral treatment and the all-important analysis of the addictive behaviors which must provide a foundation for improved theory and treatment strategies. Accomplishments of research completed and underway and needs for future investigation are discussed. The goal of all this research is, of course, to improve therapeutic outcomes and eventually to reverse the disturbing increase in preventable illnesses resulting from use of psychoactive substances. To this end, researchers are seeking to tease out the elements of those behaviors which form the antecedents, concomitants, and consequences of substance abuse. Multiple types of factors are involved: v

7 affective, biochemical, cognitive, behavioral, situational, and physiological factors at a minimum, and the mix cannot be assumed to be the same for every person. There is need for greater individualization of both treatment goals and treatment methods. For some individuals, the goal may be to regulate rather than totally to suppress the substance use. The urgency of work on long term maintenance of desired treatment outcomes is being recognized in this area where relapse is the rule. Variables determining adherence to treatment regimens also are beginning to be investigated. More stringent controls and more reliable measures are coming to be used in this research. In the past, understandably, Let s see what seems to work has often been the basis for adoption of treatment components. In seeking optimal interventions, the necessary and sufficient conditions for effecting and maintaining changes in addictive behaviors are being explored. Components of the treatment "package," which typically includes strategies to provide social support, cognitive restructuring, and development of coping skills, need to be separately tested and evaluated. It is our hope and expectation that as the base of knowledge about substance abuse behavior expands, there will be a clearer view of what the important theoretical and practical issues are, and better treatment outcomes will follow. This monograph is offered as part of NIDA s effort in that direction. William Pollin Director National Institute on Drug Abuse vi

10 Chapter 1 Introduction Norman A. Krasnegor, Ph.D. This monograph is the fifth in a series of related works published by the National Institute on Drug Abuse. These Research Monographs (Nos. 17, 18, 20, 23, and 25) address different aspects of an emerging area of research on what we call substance abuse. The term encompasses four behavioral patterns: overeating, cigarette smoking, alcohol abuse, and drug abuse. From the public health point of view, these four lifestyle factors form a set because epidemiologists have implicated then in the etiology of the major chronic diseases in the United States. Thus substance abuse behavior has been shown to contribute significantly to the onset of cardiovascular, pulmonary, hepatic, and neoplastic disease and impacts importantly upon health care and associated costs to our society. The above-stated definition is a descriptive one based upon a public health perspective. Fran the scientific and operational viewpoints, a question of great importance is whether these four behavioral patterns can be shown to be related empirically. That is, can one demonstrate experimentally that there are fundamental principles which underpin these four consumatory behaviors and thus provide a data-based rationale for grouping them as a set? Toward this end, NIDA supports the Committee on Substance Abuse and Habitual Behavior of the National Research Council. The mandate of this committee is to analyze the existing data in different scientific disciplines across the four domains of drug abuse, overeating, cigarette smoking, and alcohol abuse, and synthesize this information in order to identify empirically derived commonalities. In addition, NIDA has begun to organize the scientific research data on the behavioral aspects of substance abuse. The present monograph is a product of this effort. The papers contained in it are based on presentations made at a NIDA-sponsored conference held in Reston, Virginia, in September The conference was designed to bring together a group of scientists who are working in the area of substance abuse treatment and to produce a monograph which could 1

11 serve as a focus for examining what has been done and as a stimulus for generating new research ideas. A basic assumption inherent in the papers presented in this monograph is that substance abuse is learned, and the mechanisms which govern the usage patterns observed are fundamentally the same. A logical extension of this premise is that a valid understanding of the necessary and sufficient conditions which lead to the acquisition and maintenance of substance use and abuse can be obtained through a scientific analysis which employs the principles of operant and respondent conditioning. Once this assumption is employed as a point of departure, a research strategy for studying substance abuse can be derived from the established tactics of the experimental analysis of behavior and applied behavior analysis. Briefly, this approach posits that behavior is an observed activity of an organism. The behavior is held to have a finite probability of occurrence whose expression is functionally related to and dependent upon two features of the organism's environment. These are termed, respectively, antecedents and consequents. This triad (antecedents, behaviors, and consequents) forms the essential unit for carrying out an experimental analysis of behavior and is the fundamental. building block for the design of behavioral treatment. A behavioral analysis of substance abuse conceives of drugs, food, cigarettes, and alcohol as powerful reinforcers. The principles of operant and Pavlovian conditioning are employed by scientists and clinicians to study how these reinforcers come to exert control over behavior and to design effective treatment for these behavioral disorders. The monograph is divided into four parts. 'Drugs are the subject of Part One. A set of experiments to measure behavioral aspects of the "addictive personality" is detailed by Dr. Charles Wallace. The use of behavior therapy in connection with narcotic antagonist therapy is presented in chapter 3, by Dr. Richard Rawson and his colleagues. Dr. Roy Pickens, from the University of Minnesota, describes the behavioral program employed by him and his coworkers at his inpatient facility. A behavioral analysis of methadone detoxification failures based upon the concept of anxiety and a behavioral method to treat this problem are outlined by Dr. Sharon Hall in her paper entitled, 'The Abstinence Phobia." The final chapter in part One presents data collected by Dr. Maxine Stitzer and her colleagues at Baltimore City Hospital. She provides an account of her research on the use of contingency management to achieve abstinence from drug use and includes discussions of methodological, conceptual, and practical issues in this research domain. Part Two comprises four papers on research issues related to cigarette smoking. Dr. Terry Pechacek's paper on modification of smoking behavior presents an informative overview of the research on the behavioral methods employed to achieve cessation. The paper by Dr. Edward Lichtenstein reviews the relevance of social learning 2

12 for cigarette smoking and relates this concept to the field of substance abuse treatment research. Methodological, conceptual, and treatment issues are also discussed. Dr. Lee Fredericksen's paper entitled "Controlled Smoking" provides a review of his contributions utilizing this approach to treat cigarette smoking. The final paper is authored by Dr. Ovide Pomerleau, who has been intimately involved in the behavioral analysis and treatment of substance abuse in his role as director of the Behavioral Medicine Clinic at the University of Pennsylvania. His exposition on the commonalities inherent in substance abuse behavior Puts into focus many of the treatment and research issues germane to this field of inquiry. Part Three is devoted to papers on alcohol abuse. Dr. William Miller's paper details his and others' work on behavioral treatment of problem drinkers. The work of Drs. Peter Nathan and Thomas Lipscomb shows how psychophysical methods can be applied to elucidate ethanol blood level discrimination deficits in alcoholics. The paper by Dr. G. Alan Marlatt presents an overview of abstinence across the various types of substance abuse and suggests a cognitive behavioral model which can guide research designed to determine how to maintain abstinence once it has been achieved. In Part Four, three papers deal with the topic of obesity. Dr. Terence Wilson provides an extensive review of the literature and discusses conceptual and therapeutic issues related to the behavioral treatment of obesity. The work of Dr. Kelly Brownell focuses on a central issue in treatment, that of compliance, and how such adherence problems affect treatment success. The final paper, by Dr. Susan Wooley, presents a provocative series of counter-intuitive, data-based findings concerning obesity that should change the way we conceive of this behavioral disorder. I am extremely pleased that the National Institute on Drug Abuse has taken the lead in developing the knowledge base in the field of substance abuse. It is our hope that this and other NIDA Research Monographs will serve as both a reference and a basis for further inquiry in this field of biobehavioral research which is so directly relevant to the public health. 3

13

14 Part I Drugs

15 Chapter 2 The Effects of Delayed Rewards, Social Pressure, and Frustration on the Responses of Opiate Addicts Charles J. Wallace, Ph.D. In the search for factors that may influence the etiology and maintenance of opiate addiction, two viewpoints have prevailed. One posits that addiction is a learned behavior and the appropriate methodology for studying addiction is the same as that used for studying any learned behavior (Lynch, Stein, & Fertziger 1976; Wikler & Pescor 1967; Woods & Schuster 1971). The other posits that addiction is an "abnormal" behavior whose etiology and maintenance can be explained by reference to personality variables such as insecurity, poor self-esteem, and sociopathy. The appropriate research methodology is that of general personality theories: group studies that use as dependent variables responses to interviews and personality tests such as the Minnesota Multiphasic Personality Inventory (MMPI). It is this latter view which seem to have been dominant in both research and treatment. The thrust of numerous investigations of opiate addiction has been to delineate differences between addicts and nonaddicts using standard personality tests (e.g., Rorschach, TAT, MMPI, 16PF, I-E scale, EPPS, CPI) 1 or questionnaires developed strictly for use with addicts (Cavior, Kurtzberg & Lipton 1967: Monroe &Hill 1958: Haertzen et al. 1970; Resnick, Fink & Freedman 1970; Haertzen & Hooks 1969). Sane authors (Sutker 1971; Gilbert & Lombardi 1967) propose that there is a unique constellation of personality characteristics that predisposes an individual to addiction. Others propose that addiction is part of a general sociopathic disorder with characteristics that are shared in by all individuals who engage in proscribed behaviors (Platt 1975; Gendreau & Gendreau 1970, 1971, 1973). The evidence is contradictory; several studies have found differences between addicts and other deviant groups (e.g., Kurtines, Hogan &Weiss 1975, Sutker 1971; Sheppard et al. 1975) while other studies found no differences when variables such as age, IQ, education, and marital status were controlled (Platt 1975; Gendreau & Gendreau 1970, 1971, 1973; Sutker & Allain 1973). Irrespective of any solution to the issue of addiction "proneness," the results of these studies have been used to speculate about the components of an effective treatment program for addicts. For example, Kurtines. Hogan & Weiss (1975), based on results indicating low scores for addicts on the Socialization and Responsibility scales of the CPI, suggested 6

16 that "rehabilitation procedures for addicts might be more profitably concerned with values and personal responsiblity than with social effectiveness or a sense of personal worth" (page 89). Berzins et al. (1974), using a sophisticated clustering technique with MMPI scores, identified two subgroups of addicts and predicted that their Type I patients (peaks on 4, 8, and 2 for females and 2, 4, and 8 for males) would be more responsive to therapeutic techniques, particularly those that involve peer pressure. The usefulness of these speculations rests on the assumptions that the tests validly measure those personality characteristics enumerated by the authors and that these characteristics predict different behaviors in different treatment methods. Neither assumption is well supported; indeed, there is very little data exploring the relationship between "personality characteristics" and the behavior of addicts. The objective of this research is to explore that relationship by determining if opiate addicts can be distinguished from nonaddicts on the basis of three "personality characteristics" using as dependent measures specific, quantifiable behaviors. The three "personality characteristics" are: delay of gratification, susceptibility to peer pressure, and expression of aggression. These three were chosen because they have been frequently mentioned as being important in the etiology and treatment of addiction. It has frequently been hypothesized that addicts are either unable to delay gratification of their interpersonal and material needs, or that they lack sufficient behavioral skills to obtain gratification (Torda 1968; Dohner 1972; Fort 1954; Sharoff 1969). Laskowitz (1965) has speculated that addicts act as if there were only a "here and now." Pittel (1971) has indicated that both abusers of opiates and abusers of psychedelics can be characterized as immature and impulsive, engaging in long term relationships only to satisfy their own needs. Ranbolt and Bratten (1974) describe the addict as hedonistically seeking instantaneous gratification, while Winslow, Hankins, and Strachan (1977) note that addicts seek the immediate gratification available with drugs. There is some evidence derived from questionnaire and interview responses that supports this hypothesis. Many studies have found that addicts have an elevated score on the Pd scale of the MMPI. This presumably reflects their sociopathic traits, a major component of which is impulsivity and the inability to delay gratification (Berzins et al. 1974; Sutker 1971; Astin 1959; Gilbert & Lombardi 1967; Olson 1964). Hekimian and Gershon (1968) diagnosed 68 percent of narcotic addicts newly admitted to a psychiatric hospital as sociopathic. This was considerably more than the incidence of sociopathy for amphetamine or hallucinogen users, who were most frequently diagnosed as schizophrenic. Torda (1968), using a three hundred item biographical questionnaire, found that male heroin addicts, in contrast to matched nonaddict controls, described themselves as never having learned the skills necessary for gratification. However, Sutker & Allain (1973) and Hill, Haertzen, & Davis (1962) found no differences on the Pd scale when incarcerated addicts who have been drug free for at least two years are compared to nonaddict prisoners. Both groups score within normal limits on all clinical scales of the MMPI, indicating that the presumed sociopathy differences may reflect the immediate effects of attempting to secure drugs on the "street" rather than enduring personality differences. Corroborative evidence has also 7

17 been found by Haertzen and Hooks (1969) in a longitudinal study of prisoners who volunteered to become chronic morphine users in a controlled setting. Repeated administration of the MMPI indicated that there were no variations in the Pd scale in either chronic use or withdrawal phases. The second frequent hypothesis is that addicts are susceptible to pressure from peers to begin and continue taking drugs (Fort 1954: Sharoff 1969; Dohner 1972; Hekimian & Gershon 1968; Sheppard et al. 1972). For example. Dohner (1972) has indicated that the influence of friends was a major reason for the addiction of over one-half of a sample of Chicano addicts he interviewed. Hekimian & Gershon (1968) found similar figures, particularly in reference to marijuana usage. Sheppard et al. (1972) point out that a major component of the MMPI-derived heroin addiction scale (Cavior, Kurtzberg & Lipton 1967) is loyalty to a small group of heroin-addicted peers. Laskowitz (1965) has proposed that the heroin addict associates with a limited number of peers (two or three) with whom he can share both the risks and rewards of addiction and who, in effect, provide social reinforcement for continuing addiction. Fort (1954) has indicated that the use of drugs allows entrance into a group bound by a common ritual, language, and code of behavior. Winslow, Hankins, and Strachan (1972) postulate that peer presure and acceptance is the major reason for etiology and maintenance of addiction. The supporting evidence for the social pressure hypothesis comes principally from responses to interviews such as those used by Dohner (1972). A few experiments have been performed to test the social pressure hypothesis, and the results have been equivocal. Diamond (1956) compared the responses of adolescent heroin addicts and nonaddict schizophrenics to an Asch type group pressure situation. Results indicated that schizophrenics were not influenced by group pressure, while addicts were influenced. A normal control group would have helped considerably in interpreting these results. Singer (1962) used the Rod and Frame Test to compare the responsiveness to environmental influences of adolescent heroin addicts and matched delinquent and nondelinquent controls. He found no differences. Haertzen and Hooks (1969), in their longitudinal study of chronic morphine use, found that chronic use was associated with a withdrawal from social activityand greater irritation and boredom withothers. The third frequent hypothesis is that aggression is a critical factor in opiate use. There are, however, two rather different views of the relationship between addiction and aggression. It has been suggested that addiction represents a direct expression of aggression toward authority figures and a rebellion against rules and authority (Smith 1973; Dohner 1972; Sheppard et al. 1972; Winslow, Hankins & Strachan 1972). Smith's (1973) results, based on personality inventories and questionnaires administered annually to 15,000 Boston school children, indicate that the best predictor of future drug use in a sample of fourth grade to twelfth grade students is rebelliousness to authority figures. The more rebellious, the greater the potential for the later use of drugs. Dohner (1972) has indicated that adolescents may begin the use of drugs as "part of the need to defy societal or parental authority" (page 321). Sheppard et al. (1972) have indicated that one of the major factors of the MMPI-derived heroin addiction scale concerns feelings of resentment to authority figures and an enjoyment of flouting the rules. On the other hand, it has been suggested that addiction is initiated and maintained as an escape from the stress generated by aggressive feelings 8

18 which the addict is unable to express (Torda 1968; Fort 1954; Fischmann 1968). Fort (1954) postulates that the most significant factor in heroin addiction is "the enormity of the addict's aggression," from which the addict escapes by using drugs. Torda (1968), based on the results of a 300-item biographical questionnaire, proposes that the addict dreads the expression of aggression and injects heroin as a relief from the panic that such dread elicits. Fischmann (1958) views narcotics in particular as an avoidance of aggression. Laskowitz (1965) has suggested that the relationship between aggression and addiction may be different for different types of addicts. Laskowitz proposes that, for one type, drug injection acts as a cue for the expression of anger which would otherwise not be admitted. For another type, drug use may decrease almost constant feelings of anger and irritability. Reith, Crockett, and Craig (1975) found that addicts have both high aggressivity and a high need for succorance as measured by the Edwards Personal Preference Schedule. They note that these are contradictory needs, involving a conflict that would be extremely difficult to resolve. In spite of this mass of findings there is a dearth of evidence that relates these interview and questionnaire responses to behavior in a well-controlled laboratory situation, let alone in more clinically relevant, less controlled situations. The objective of this research was to determine if addicts could be differentiated from nonaddict delinquents and nonaddict nondelinquents on the basis of their behavior during three experimental tasks. The tasks were designed to measure the three 'personality characteristics" of ability to delay gratification, susceptibility to social pressure, and ability to cope with frustration. A second objective was to determine if ethnicity is a significant predictor of differences in either the questionnaire responses or in the laboratory behavior. Ethnicity has been given little attention except for an occasional differential prediction in the clinical literature (Dohner 1972). METHOD Subjects A total of 45 males and 30 females participated in the procedures. For both sexes, the participants consisted of 15 nonaddict nondelinquents and 15 addicts; the male subjects included an additional 15 nonaddict delinquents. Each group of 15 was composed of 5 Anglos, 5 blacks, and 5 Chicanos. The addict subjects' participation was solicited on the day of their admission to a community-based detoxification center. If they agreed to participate, the procedures were administered at the center on the fourth and fifth days of their planned 14-day stay. The nonaddict delinquent males were selected from participants in a prerelease program at a local state prison, all of whom had been incarcerated for a minimum of two years. All subjects were classified as nonaddicts based on two criteria: (1) case records did not indicate an arrest for an offense involving the use or possession of drugs; (2) a self-report of not now or in the past having consistently used cocaine, morphine, heroin, barbiturates, amphetamines, or alcohol for a period of more than one year

19 The nonaddict nondelinquent subjects were solicited through ads placed in the local college newspapers and in the newsletter of a local neuropsychiatric facility. In addition to fulfilling the criteria for classification as a nonaddict, subjects were classified as nondelinquent based on their self-report of not having been arrested for more than a misdemeanor, nondrug-related traffic offense. The originial sampling plan had specified that nonaddict delinquents would be selected from the rolls of local probationers and from enrollees in a work furlough program operated by the local probation department. However, an inspection of the case records indicated that approximately 95 percent of the potential subjects had been convicted of drug use as a primary or secondary offense. Officials of the probation department further indicated that probably more than 95 percent were currently using drugs. They suggested that the only delinquents not involved in drug use might be those individuals who had been incarcerated because of relatively serious offenses. Officials of the state prison system were contacted and, although they endorsed the project, no administrator of a prison for female offenders would allow recruitment of subjects. The only administrator of a prison for male offenders to agree to solicitation of subjects restricted recruitment to prerelease prisoners. Procedures The procedures were administered in two sessions. For the first session, subjects were asked to complete a demographic questionnaire plus several personality tests including the MMPI-168, the Emotions Profile Index (EPI), the Self Control (SC) and the Socialization (So) scales of the California Psychological Inventory (CPI), the Slosson IQ test, the Institute for Personality and Aptitude Testing (IPAT) Anxiety Test, and the State Trait Anxiety Inventory (STAI). Subjects were given the standard written instructions for each test; questions were answered by referring subjects to the relevant sections of the instructions. For the second session, which was generally administered on the following day, subjects participated in three tasks designed to test the hypotheses of the project. Al three tasks were operationalized using a custom-built human test console controlled by a minicomputer (PDP8-A). The console, which was 24" x 21" x 23", was placed on a desk, with subjects seated directly in front of it. The console consisted of several different manipulanda, reinforcement dispensers, and stimulus display devices. After subjects were acclimated to the testing situation, they were administered Task 1. The task provided subjects with 30 choices between a small, inmediately delivered reward and a larger, delayed reward. The small reward was a nickel, which was dispensed as soon as the subjects made their choices. The delayed reward was a token which was eventually exchanged for a dime. The token was dispensed as soon as the subjects made their choices; the exchange was delayed until 10 days after completion of the session. Subjects indicated their choices by pulling one of two Lindsley manipulanda. The relationship between the manipulanda and the rewards alternated from trial to trial so that pulling one manipulandum dispensed a nickel on one trial, and a token on the next trial, with the opposite relationship in effect for the other manipulandum. To inform subjects of the alternation, discriminative stimuli were used such that 10

20 a red light signaled one relationship between manipulanda and rewards and a white light signaled the opposite relationship. Subjects not only read detailed instructions about the alternation, but they were reminded of the relationships by labels placed just above each manipulandum. Completion of the first task generally took from 7.5 to 10 minutes; subjects then participated in the second task, which operationalized the social pressure conditions. The task was a modified Asch task in which subjects were asked to select from four vertical lines the one they thought matched a vertical line they had just viewed. 'The four vertical lines and a standard line were presented on slides projected onto a 3.75" x 3.75" rear projection screen located on the console immediately in front of the subjects. The slide of the standard line was exposed for 7 seconds followed by presentation of the slide of the four lines, which was not-removed from view until subjects made their choices. Unlike the Asch task, the four lines were drawn so that there was no correct choice and the difference between the lines was extremely small (a maximum of 1/32" when the lines were drawn to a scale of 8" long). There were forty different pairs of standard and choice slides; pretesting indicated that, for all pairs of slides, no one alternative was chosen significantly more often than would be expected on the basis of chance responding (25 percent). Two independent variables were implemented within this paradigm, and all subjects participated in all levels of both variables. One variable was the mount of social pressure. Subjects were told that the task required an extremely difficult perceptual discrimination and, to assist them, they would be given the answers of four other subjects who had previously taken the test and who had presumably agreed to make their answers known. The answers were displayed on a 4 x 4 matrix of lights which was placed just above the rear projection screen. There were four levels of social pressure: all four of the others presumably agreed on one alternative; three of the others agreed on one alternative but the fourth disagreed; two of the others agreed on one answer with the other two disagreeing with the first two and between themselves; no two of the four agreed on one answer. Subjects indicated their answers by pressing one of four pushbuttons located just above the 4 x 4 matrix of lights. Of the forty sets of slides, ten were presented under each level of social pressure. The other variable was type of social pressure, i.e., answers presumably left by peers and answers presumably left by nonpeers. To operationalize these two conditions, subjects viewed video tapes in which the four who had left their answers gave brief descriptions of themselves. For the peer condition, subjects viewed same sex and ethnicity confederates who, depending upon the subject's classification, described themselves as either going to college (nonaddict, nondelinquent), in trouble with the law but not using drugs (nonaddict, delinquent), or in trouble with the law and using opiates (addicts). The same confederates, who ranged in age from 21 to 28, were used for all variations. For the nonpeer condition, all subjects regardless of sex, ethnicity, or classification, viewed a tape of two nurses, a businessman, and a research sociologist briefly describing themselves and their jobs. Subjects viewed one of the tapes and then responded to the forty sets of slides; after a 5 minute break, they viewed the remaining tape and 11

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